Method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person enrolled without regard to the actual number or nature of service provided or number of persons served.

Cost-sharing

Provision of a healthcare insurance policy that requires policy holders to pay for a portion of their healthcare services; A cost-control mechanism.

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Fee for Service reimbursement

Healthcare payment method in which providers retrospectively receive payment for each service rendered.

Gatekeeper

Healthcare provider or entity responsible for determining the healthcare services a patient or client may access. The gatekeeper may be a primary care provider, a utilization review or case management agency, or a managed care organization.

HMO – Health Maintenance Organization

Entity that combines the provisions of healthcare insurance and the delivery of health care services.

Episode of Care Reimbursement

Healthcare payment method in which providers receive one lump-sum for all the care they provide releated to a disease or conditon.

Global Payment

Method of payment in which the 3rd party payer makes one consolicated payment to cover the services of multiple providers who are treating a single episode of care.

IPA (Independent Practice Association or Organization-IPO)

Type of health maintenance organization in which participating physicians maintain their private practices and the HMO contracts with the independent practice association. The HMO reimburses the IPA onb a capitated basis and the IPA reimburses the physicians on either a fee-for-service or a capitated basis.

MCO

Entitiy that integrates the financing and delivery of specified healthcare services. Also known as coordinated care organization.

Network

Physicians, hospitals, and other providers who provide healthcare services to members of a managed care organization. Providers may be associated through formal or informal contracts or agreements.

PMPM (per member per month)

Amount of money paid monthly for each individual enrolled in a capitization-based health insurance plan.

POS (Point of Service- Health Insurance Plan)

Plan in which members choose how to receive services at the time they need the services. Also known as open ended HMOs.

Preauthorization

Process of obtaining approval from a healthcare insurance company before receiving healthcare services. Also known as Precertification of Prior approval.

Precertification

Process of obtaining approval from a healthcare insurance company before receiving healthcare sercices. Also known as Preauthorization or Prior approval.

PPO (Pro-offered Provider Organization)

Entity that contracts with employees and insurers to render, through a network or providers, healthcare services to a group of members. Memebers can choose to use the healthcare services of any physician, hospital,or other healthcare provider. Members who choose to use the services of in-network (in plan) providers hacve lower ou-of-pocket expenses than members who choose to use the services of out-of-network (out of plan) providers.

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PCP (Primary Care Provider)

Physician, who provides supervises and coordinates the healthcare of a member. The PCP makes referrals to specialists and for advanced diagnostic obstetricians/gynecologists, nurse practitioners and physican assistance are primary care.

Uncompensated Care

Overall measure of services provided for which no payments were received form the patient, client or third party payer.

Withhold

Also known as Physician Contingency Services (PCS). Portion of providers capitated payments that managed care organizaitons deduct and hold in order to create an incentive for efficient or reduced use of healthcare services.

CMS-Centers for Medicare and Medicaid Services

A division of the Department of Health and Human Services (DHHS) that is responsible for administering the Medicare program and the federal portion of the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM). Prior to 2001, CMS was named Health Care Financing Administration (HCFA).

Indian Health Services (IHS)

An agency within the Department of Health and Human Services (DHHS) responsible or upholding the federal governments obligation to promote healthy American Indian and Alaskan native people, communities and cultures.

Medicaid

Part of the Social Security Act, a joint program between state and federal governments to provide healthcare benefits to low-income persons and families.

Medicare

Federally funded healthcare benefits program for those persons 65 years of age and oder, as well as for those entitled to Social Security benefits.

Medicare Advantage (Part C)

Optional managed care plan for Medicare beneficiaries who are entitled to Part A, are enrolled in Part B, and live in an area with a plan. Types of plans available include health maintenance organizaiton, point of service plan, preferred provider organizaiton and procvider-sponsored organization (formerly Medicare +Choice).

Medicare Part A

The portion of Medicare that provides benefits for inpatient hospital services.

Medicare Part B

An optional and supplemental portion of Medicare that provides benefits for physician services, medical services and medical supplies not covered by Medicare Part A.

Medicare Part C

Also known as Medicare Advantage, this is a managed care option that includes services under Part A, B, and D and additonal services that are not typically covered by Medicare; Medicare Part C requires an additional premium; plan known forerly as Medicare +Choice.

Medicare Part D

Medicare Drug benefit created by the Medicare Modernization act of 2003 (MMA) that offers outpatient drug coverage to beneficiaries for an additional premium.

Medigap

Type of private insurance policy available or Medicare beneficiaries to supplement Medicare Part A and/pr Part B coverage.

State Children's Helath Insurance Program (SCHIP)

A state-federal partnership created by the Balanced Budget Act of 1997 that provides health insurance to children of families whose income level is too high to qualify for Medicaid but too low to purchase healthcare insurance.

What recent legislation made a substantive change to Medicare benefits, and how did they change?

The most significant recent legislative change to Medicare was the Medicare Modernization Act of 2003 (MMA). MMA created an outpatient prescriptin drug benefit, provided beneficiaries with expanded coverage choices, and improved benefits.

List at least three types of Medicaid recipients required for states to qulify for federal matching funds

1. Based on average income perperson living in that state

2. Low income families with children

3. Including families that qualify for TANF (Temporary Assistance for Needy Families)

What is the target population of the State Children's Health Insurance Program (SCHIP) (Title XXI)?

Designed to provide coverage to chidren whose family income may be too high to qualify for Medicaid, but too low to afford private health insurance.

What program covers healthcare costs and lost income from work-related injuries or illness of federal government employees?

The Federal Employee's Compensation Act (FECA)

Individuals eligible for Railroad Retirement disability or retirement benefits are ineligible for Medicare. True or False?

True

Individuals who are elibible may choose between TRICARE benefits and CHAMPVA. True or False?

False. TRICARE replaced CHAMPVA

In state having no mandated workers' compensation fund, employers must purchase insurance from private carriers or provide self-insurance coverage. True or False?

True

Describe at least three ways in which MCOs work toward their goal of quality patient care.

1. Manage costs

2. Manage outcomes

3. Integrate finaancing & delivery of healthcare services.

From where do evidence-based clinical guidelines originate?

a. Foundational Principles of Care for certain conditions.

b. Developed from scientific evidence & clinical expertise.

List at least two reasons that MCOs survey their members for feedback.

1. Suggestions for improvements.

2. Intentions regarding re-enrollment.

3. Satisfaction with administrative, clinical and customer services.

Name the three steps in medical necessity and utilization review.

1. Initial Clinical Review

2. Peer Clinical Review

3. Appeals Consideration

Describe three types of cost controls used by MCOs.

1. Method of Reimbursement

2. Service Management Tools

3. Financial Incentives

Which type of HMO offers patients the least selection in referrals to specialists?

a. Staff Model is the most controlled of the HMOs.

b. Primary care physicians control the referrals to specialists within the HMO.

c. Members who recieve care out of the HMO network will not receive compensation for their healthcare costs.

List at least five types of services or populations that are common examples of carve outs.

1. Long-term Management

2. High-cost

3. Managed by one group specialists

4. Not usually managed by primary care providers

5. Sub-capitation = a common payment for specialist services.

Integrated delivery systems typically have horizontal rather than vertical integration of servies. True or False?

False

MMA

Medicare Modernizaiton Act of 2003

TANF

Temporary Assistance For Needy Families

PACE

Programs of All-Inclusive Care for the Elderly

SCHIP

The State Chilren's Health Insurance Program

CHAMPVA

Civilian Health and Medical Program Veterans Administration

IHS

Indian Health Services

AFDC

Aid to Families with Dependent Children Program

BBA

Balance Budget Act of 1997

DHHS

Department of Health and Human Services

CHAMPUS

Civilian Health & Medical Program of the Uniformed Services

NOAA

National Oceanic & Atmospheric Administration

ADSMs

Active-Duty Service Members

ADFMs

Active-Duty Family Members

DEERS

Defense Enrollment Eligibility Reporting System

TFL

TRICARE for Life

CHAMPVA

Civilan Health and Medical Program of the Department of Veterans Affairs

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